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Client Intake Form
I Am Well Client Information 2022
Email *
Name *
Address *
Phone number
Date of Birth *
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Emergency Contact: Name and phone number *
Are you currently under the care of a physician for a particular condition?   *
Required
Do you have any metal implants, medical implants or replacements?           *
Required
Please describe implants
Are you pregnant?                                                                                               *
Required
Are there any other medical issues or concerns I should be aware of?  Please describe below.
Have you ever had a Reiki session before?   *
Required
Have you ever had an EFT session before?   *
Required
Have you ever had a VST(sound) session before?   *
Required
Do you have a particular area of concern or focus for your session? Please describe below. *
How did you hear about Danielle and I Am Well? *
Is there anything else that I should know that would help me to be prepared for your session?
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